Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer
Chen et al. BMC Cancer
Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer
Lantao Chen 0 1
Lixin Sun 0 3
Yaoguo Lang 1
Jun Wu 1 2
Lei Yao 1
Jinfeng Ning 1
Jinfeng Zhang 1
Shidong Xu 1
0 Equal contributors
1 Department of Thoracic Surgery, Harbin Medical University Cancer Hospital , Harbin, Heilongjiang Province , China
2 Department of Thoracic Surgery, Hainan Cancer Hospital , Haikou, Hainan Province , China
3 Department of Thoracic Surgery, The Fourth Affiliated Hospital of Harbin Medical University , Harbin, Heilongjiang Province , China
Background: Our aim was to investigate the influence of FTS on human cellular and humoral immunity using a randomized controlled clinical study in esophageal cancer patients. Methods: Between October 2013 and December 2014, 276 patients with esophageal cancer in our department were enrolled in the study. The patients were randomized into two groups: FTS pathway group and conventional pathway group. The postoperative hospital stay, hospitalization expenditure, and postoperative complications were recorded. The markers of inflammatory and immune function were measured before operation as well as on the 1st, 3rd, and 7th postoperative days (POD), including serum level of interleukin-6 (IL-6), C-reactive protein (CRP), serum globulin, immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA) and lymphocyte subpopulations (CD3 lymphocytes, CD4 lymphocytes, CD8 lymphocytes and the CD4/CD8 ratio) in the patients between the two groups. Results: In all, 260 patients completed the study: 128 in the FTS group and 132 in the conventional group. We found implementation of FTS pathway decreases postoperative length of stay and hospital charges (P < 0.05). In addition, inflammatory reactions, based on IL-6 and CRP levels, were less intense following FTS pathway compared to conventional pathway on POD1 and POD3 (P < 0.05). On POD1 and POD3, the levels of IgG, IgA, CD3 lymphocytes, CD4 lymphocytes and the CD4/CD8 ratio in FTS group were significantly higher than those in control group (All P < 0.05). However, there were no differences in the level of IgM and CD8 lymphocytes between the two groups. Conclusions: FTS improves postoperative clinical recovery and effectively inhibited release of inflammatory factors via the immune system after esophagectomy for esophageal cancer. Trial registration: ChiCTR-TRC-13003562, the date of registration: August 29, 2013.
Esophageal cancer; Fast-track surgery; Cellular immunity; Humoral immunity
Background
Since its introduction in the 1990s, the concept of
fasttrack surgery (FTS) has gained widespread acceptance
and is now considered as a standard of care. FTS also
referred to as enhanced recovery after surgery (ERAS)
have been implemented in order to enhance recovery,
reduce morbidity and mortality rates, and shorten
hospital stay after major surgery. The aim of this novel
approach to perioperative patient care is to decrease the
perioperative stress response to the surgical trauma and
thereby leading to a decrease in complication rates in
surgery. These promising clinical results lead to the
question of whether the concept of FTS also results in
better-preserved immune function in the postoperative
course. Some researchers believe that FTS also has
positive effects on the human immune system, which may
result in quicker recovery of postoperative immune
function [
1
]. Nevertheless, few clinical studies results
have reported the impact of FTS on human immunity.
Therefore, based on the hypothesis and present evidence
of the benefits of FTS, we prospectively studied 276
patients underwent esophagectomy for esophageal
cancer who either received FTS pathway or conventional
pathway in the perioperative period. In addition to
clinical outcome parameters, we analysed the effects of
FTS on proinflammatory cytokine IL-6 and CRP levels
as well as immunoglobulin and lymphocyte subgroups
before surgery and on days 1, 3 and 5 after surgery.
Methods
Patients and procedures
This study was conducted in the Department of
Thoracic Surgery at Harbin Medical University
Cancer Hospital from October 2013 to December 2014.
Inclusion criteria included: age ≥18 and ≤75 years,
American Society of Anesthesiologists (ASA) grade I/
II, body mass index (BMI) 18.5–27.5 kg/m2,
resectable esophageal cancer (page 36, NCCN Guidelines
version 1.2013). However, we found in our previous
clinical study involving patients with confounding
factors that such factors might have a great impact on
the results, such as immunological parameters for
both controlled and observational groups. Therefore,
some patients needed to be excluded from our study.
The exclusion criteria of the study were as follows:
patients with known immunological dysfunction
(advanced liver disease (decompensated cirrhosis,
portal hypertension or hepatocellular carcinoma), HIV
infection, hepatitis C virus infection), (...truncated)